PHASE 34 APPLICATION AND DOCUMENTATION

EMERGENCY FOOD AND SHELTER PROGRAM

MCLEAN COUNTY, ILLINOIS

In order to submit a successful application, the following materials must be completed and submitted:

·  Phase 34 Application (Included Below)

·  Local Recipient Organization Certification Form (Included Below)

·  If nonprofit, agency must attach a copy of the current board roster.

·  Copy of Agency’s most recent annual audit

·  (If applicable) Phase 34 Fiscal Agent/Fiscal Conduit Agency Relationship Certification (Contact David for Form)

DEADLINE FOR APPLICATION: August 04, 2017 at 4:30 p.m.

Applications are to be turned in via electronic delivery to:

David Taylor, President and CEO

United Way of McLean County

201 E Grove St

Bloomington IL 61701

PHASE 34 APPLICATION
ORGANIZATION INFORMATION
1. / Agency’s Legal Name :
2. / Agency principal/executive director/CEO:
a. Contact information (Email, Phone):
3. / Agency contact for application questions:
a. Contact information (Email, Phone):
4. / Agency Contact for EFSP, if funded:
a. Contact information (Email, Phone):
5. / Agency physical address:
6. / Congressional district where agency is located:
7. / Agency Mailing address:
8. / Agency Website:
9. / Agency Federal Employer Identification Number (FEIN):
10. / Agency DUNS Number:
11. / Agency’s Total Operating Budget
12. / Agency’s total budget for the program area(s) requested:
a. Served Meals
b. Other Food
c. Mass Shelter
d. Rent
e. Utility
13. / Is agency nonprofit or unit of government? / □ YES / □NO
14. / Is agency debarred or suspended from receiving funds or doing business with the Federal Government? / □ YES / □NO
15. / Number of years organization has been in operation:
16. / Purpose/mission statement of organization that will provide services:
FUNDING REQUEST INFORMATION
Maximum of 1,000 characters allowed per question (includes spaces).
17. / Agency Address for Place of Performance
(where EFSP funded services are provided):
18. / Congressional district where agency’s EFSP funded services are provided:
19. / Total Amount requested of EFSP funding:
20. / Amount of EFSP funding requested by program area (should equal total amount requested):
a. Served Meals ($2.00/Meal Rate)
b. Other Food
c. Mass Shelter ($7.50 or $12.50/Night Rate)
d. Rent
e. Utility
21. / Did you receive funds in past phase(s)? / □ YES / □NO
a. If so, have you been out of compliance at any time during the past three phases? / □ YES / □NO
i.  If yes, please explain:
22. / Did your agency return unexpended funds in any previous phase(s)? / □ YES / □NO
a. If yes, provide the following information:
-state amount,
-category of programming (food, rent, etc.) and
-explain why the funds were not spent.
23. / Include a brief paragraph describing the experience and expertise of your agency and staff involved in managing EFSP funding.
24. / Please explain your experience in handling assistance requests, processing funds and maintaining the required documentation.
25. / For each of the program areas the agency has requested funding, please provide the following information:
a. # of years these services have been offered;
b. # of staff administering these services;
c. # of volunteers assisting with these services;
d. If applicable, # of clients/households served in
Phase 33 (specify individuals or households)
26. / How will the agency use EFSP funds to expand/enhance/ maintain services to otherwise
un-served and/or underserved populations.
27. / Include a brief paragraph explaining why you are requesting funding in each particular category (food, rent, etc.) and how this funding will impact the need for the services in your area (one paragraph per category for which funding is being requested). If any program categories do not apply, please put N/A.
a. Served Meals
b. Other Food
c. Mass Shelter
d. Rent
e. Utility
BREAKDOWN OF GRANT REQUEST
Provide the amount requested for individual services and the number of units per service you plan to provide.
(Estimating the number of meals or nights of shelter to be paid with EFSP funding.
For rent and utility expenditures, estimate the number of bills to be paid.)
SERVICE CATEGORIES / DOLLARS REQUESTED / UNITS/BILLS / CLIENTS SERVED
(Please label individuals/households)
Served Meals
($2.00/Meal Rate) / ______# of meals
Other Food / ______# of meals
*Mass Shelter
($7.50 or $12.50/Night Rate) / ______# nights
Rent/Mortgage Assistance / ______# of bills
Utility Assistance / ______# of bills
Total Request
*For Mass Shelter applicants, please explain why the organization has chosen the $7.50 or $12.50/night rate.